Implementation strategies for the new World Mental Health Report in low‐resource settings
Authors: Pratap Sharan
Journal: World Psychiatry (2022)

Mental health conditions are very burdensome for all societies, and the situation has been made worse by the COVID-19 pandemic. Yet, health and social systems of most countries are poorly geared to take care of mental health needs of people and populations. The "care gap" is directly responsible for enormous suffering and frequent human rights violations. The World Health Organization (WHO) and the global mental health community have been trying to close the "care gap" for at least three decades, and have achieved some success in relation to interest in and understanding of mental health issues, amplification of voices of people with lived experience of mental health conditions, generation and compilation of relevant research, development of evidence-based implementation tools, and global governance and leadership (e.g., WHO Comprehensive Mental Health Action Plan 2013-20301). But progress has been slow, as mental health systems and services remain ill-equipped to meet people's needs in most countries. Inequities, in fact, have become worse during the COVID-19 pandemic in many settings. The new World Mental Health Report: Transforming Mental Health for All emphasizes the urgency of the action needed to ensure better mental health for the world's population2. The report suggests that this can be achieved by deepening the value and commitment given to mental health, reshaping the environments that influence mental health, and developing community-based mental health services capable of achieving universal health coverage (UHC) for mental health. From the perspective of low- and middle-income countries (LMICs), the report provides useful strategic guidance, evidence on successful delivery and scaling up of effective interventions across poor-resource settings, and a compilation of implementation tools (e.g., the ICD-11; the WHO World Mental Health Surveys; the mhGAP Intervention Guide; the EQUIP: Assessing and Building Competencies for Psychological Interventions; the WHO QualityRights; the Mental Health and Psychosocial Support Minimum Service Package; and the WHO UHC Compendium) to support them in their efforts to achieve this ambitious transformation2. It also highlights that, in many settings, digital technologies can be used to strengthen mental health systems2. The report also showcases narratives from many LMICs of people with lived experience of mental health conditions that show that people's expectations from and needs for effective health and social support are not so different from those in better resourced settings. However, a sobering fact is that, despite global efforts to correct the "care gap", the proportion of people with common mental disorders who receive minimally adequate care is between 1% in low-income countries and 10% in better resourced middle-­income countries such as India and China3, 4. The gap could well be increasing – the India State-Level Disease Burden Initiative shows that the proportional contribution of mental disorders to the total disease burden in India almost doubled from 1990 to 20175. Also, key threats to public mental health and development such as economic downturns and social polarization, public health emergencies, humanitarian emergencies and forced displacement, and the climate crisis disproportionately affect the populations living in LMICs2. The new report exhorts countries to take transformative action based on local realities. However, this recommendation is faced with a huge "implementation gap". Many LMICs have significant structural barriers that limit the scaling up of services when they attempt it on their own. The governments of many low-income countries have very little to spare for mental health from their low overall government expenditure; similarly, low resource middle-income countries find it difficult to secure the double funding needed to scale up community mental health care while somehow managing their precarious specialized men­tal health care6. There has been a call for a multi-sectoral and multi-organizational partnership for global mental health to address the challenge of financing and stewarding a global scaling up of mental health services7. But, in view of the complexity of determinants and heterogeneity of conditions characterizing mental health, a strategy modelled on the United Nations (UN)'s Every Woman Every Child strategy – that coordinates WHO's Partnership for Maternal, Newborn and Child Health and World Bank's Global Financing Facility – may be better suited to support the scaling up of services for mental health. Such a strategy may also be well placed to utilize the Health4Life Fund on non-communicable diseases (NCDs) and mental health established in 2021 under the auspices of the UN Interagency NCD Task Force. This Fund is designed to support LMICs with initial grants to stimulate multi-stakeholder and multi-sectoral action at country level, increase domestic funding, and improve policies, legislation and regulation. Regional interagency mechanisms such as the Every Woman Every Child Latin America and the Caribbean initiative could deepen implementation of global strategies at the regional level through data-driven advocacy, capacity building, and policy and program solutions8. The big question is: "Will different departments and programs of WHO and of other UN agencies work together to implement the new Mental Health Report vision?". The report suggests that countries should set up in-depth processes to adapt global recommendations to their local context, e.g., to weigh up needs, resources, evidence of impact and models of intervention to ensure that resources are allocated, and services provided, appropriately and efficiently. But many national health authorities in LMICs do not have the technical capacity for evaluating the increasingly voluminous and complex scientific data. These needs could be handled by the creation of National Mental Health Technical Advisory Groups (on the lines of National Immunization Technical Advisory Groups)9 with a legislative or administrative status within countries. Such bodies could empower governments to formulate rational policies through evidence-based decision-making and help adapt global recommendations to local contexts for the entire range of mental health actions. National Mental Health Technical Advisory Groups should comprise multidisciplinary groups of national experts (e.g., academics and health care professionals, scientific societies and non-governmental organizations, and representatives from civil society). They could collect, review, assess and organize scientific evidence on specific mental health-related topics; offer specialized technical and operational assistance to improve levels of implementation; and provide a monitoring function to maintain momentum towards agreed-upon targets and goals, and suggest course corrections when needed. The WHO could perhaps recommend that countries establish such bodies through the World Health Assembly resolution towards the attainment of the WHO Comprehensive Mental Health Action Plan 2013-2030 goals (the number of Technical Advisory Groups established or strengthened could itself serve as a target for global mental health response). The WHO and its partners (including funding agencies) could support countries to establish their Technical Advisory Group, network it with ­local and regional collaborators, and strengthen its capacity to use evidence-based processes for decision-making aligned with international stan­dards. Will WHO come forward to assist countries in developing the technical capacity that is sorely needed in LMIC capitals, from New Delhi to Maseru? The new World Mental Health Report is a welcome opportunity to harness and catalyze the growing momentum towards ­applying the large body of scientific evidence to achieve a scaling up of effective interventions for mental health and well-being globally and specifically in low-resource settings.